Implementing Empirically Supported Treatments:

1
Implementing Empirically Supported Treatments

• Psychotherapy Outcome Research in a
  Hospital-Affiliated Outpatient Clinic
• (Mission Impossible or Little Engine That Could?)
• Ruth W. McPhearson, Ph.D.
• Martin Langhinrichsen Rohling, Ph.D
• Memorial Behavioral Health
• Memorial Hospital at Gulfport, MS

2
Overview of Introductory Comments

• 1. Is psychotherapy efficacious?
• If so, is it also effective?
• 2. Can we be prescriptive in treatment?
• 3. Why do I need to use ESTs?
• What is the relationship between effectiveness
  and clinical experience?
• What if I dont use EST, how effective am I with
  my patients (treatment as usual in clinic
  setting)?

3
Does Psychotherapy Work?

• Findings from meta-analyses
• Smith, Glass, Miller (1980)
• ES .85 475 studies included in analysis.
• Lipsey Wilson (1993) meta-analyzed all
  published meta-analyses for Psychological,
  Educational, Behavioral Treatments
• ES .50 302 meta-analyses included in study.

4
So its Efficacious doctor!Is it Effective?

• Efficacious means that a treatment worked in a
  controlled laboratory setting and the research
  design was internally valid
• Good 1st step. Necessary but not sufficient!
• Effective means that a treatment worked in the
  real world of the uncontrolled clinic setting,
  i.,e., it is transportable and externally valid.
• Required before we throw caution to the wind
  and start using it!

5
So It Works! Now What

• Early findings (Smith, Glass, Miller, 1980)
  found no differences for modality of therapy.
• Behavioral, Psychodynamic, Humanistic, etc. all
  appeared equally efficacious.
• Recent findings suggest this is erroneous
  (Ollendick King, 2000).
• We are in an era of Prescriptive Treatments
• Some treatment are better for some
  disorders/symptoms than are others (e.g., CBT for
  depression as been shown to be more efficacious
  than Psychodynamic).

6
Manual! Manual! We dont need no stinkin manual!!

• Several research paradigms have found that
  clinicians (MD PhD) confidence effectiveness
  (diagnostic or treatment outcome) are inversely
  correlated (e.g., Fischhoff, 1982).

7
Is knowledge really wasted on youth?

• Furthermore, clinical experience has little to no
  association with effectiveness.
• However, clinical experience is positively
  correlated with confidence.
• So who needs the manuals?
• Us or Them

8
So What if I Dont Use EST?

• What is the state of treatment as usual in
  clinical practice settings?
• Weisz, Huey, Weersings (1998) meta-analysis
  found that the mean ES .01, which is not
  significantly different from 0.
• Treated patients no better than untreated!
• Furthermore, ESs ranged from -.40 to .29.
• Some clinicians made patients worse by treatment!

9
Some thoughts about the forest before getting
into the trees.

• Prochaskas et al.s (1992) stages of change
• 1. Precontemplative No problamo
• 2. Contemplative Give me time, Ill get to it
• 3. Preparation Planning, planning, more
  planning
• 4. Action Its time to either sh-- or get off
  the pot
• 5. Maintenance Relapsing and recycling
• Institutions vs. clinicians readiness to change
• Incongruence leads to frustration burn-out.

10
Issues to be discussed (1)

• How much time does this take?
• When will we be done?
• How much energy does this take?
• Will I make more money?
• How do MHC/3rd party insurers look at this?
• Might I lose money by devoting too much time to
  training and supervision

11
Issues to be discussed (2)

• What if the administration doesnt back me?
• What if my staff dont follow the ESTs I
  prescribe?
• Can or should I fire them (Employment Law)?
• How do I know if Im doing it right?
• More intensive supervision required
• Outcome data used for benchmarking